Provider Demographics
NPI:1063627214
Name:VYAS, AMIT (MD)
Entity type:Individual
Prefix:
First Name:AMIT
Middle Name:
Last Name:VYAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 FORT JESSE ROAD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6289
Mailing Address - Country:US
Mailing Address - Phone:309-452-1788
Mailing Address - Fax:309-862-1302
Practice Address - Street 1:2200 FORT JESSE ROAD
Practice Address - Street 2:STE. 280
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6289
Practice Address - Country:US
Practice Address - Phone:730-945-2178
Practice Address - Fax:309-862-1302
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010819532085R0202X
IL036.1232442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123244Medicaid
IL036123244Medicaid